Renewing the Fight:

A Call to Action for Diabetes

and Chronic Kidney Disease

A policy brief by the International Diabetes Federation

and the International Society of Nephrology
CONTENTS
CONTENTS .................................................................................................................................................................................................................................................................................................... 2
INTRODUCTION...................................................................................................................................................................................................................................................................................... 3
About this Policy Brief.........................................................................................................................................................................................................................................................3
About the International Diabetes Federation...................................................................................................................................................................................... 3
About the International Society of Nephrology................................................................................................................................................................................. 3
THE GLOBAL IMPACT OF DIABETES AND KIDNEY DISEASE........................................................................................................................... 4
What is Diabetes........................................................................................................................................................................................................................................................................4
What is Chronic Kidney Disease ...........................................................................................................................................................................................................................5
Diabetes and Kidney Disease Prevalence Worldwide ............................................................................................................................................................... 6
Diabetes and Chronic Kidney Disease on the Political Agenda...................................................................................................................................... 7
Causes of Diabetes..................................................................................................................................................................................................................................................................9
Causes of Chronic Kidney Disease................................................................................................................................................................................................................... 10
Causes of CKD in People Living with Diabetes................................................................................................................................................................................. 11
CKD in People Living with Diabetes: Implications for Cardiovascular Risk and Total Mortality........................................ 11
The Impact of CKD for People Living with Diabetes and Healthcare Budgets........................................................................................ 13
ADDRESSING DIABETES AND CKD IN PEOPLE LIVING WITH DIABETES............................................................................ 14
Diabetes Prevention........................................................................................................................................................................................................................................................... 14
Screening for CKD in People Living with Diabetes...................................................................................................................................................................... 14
Addressing the Different Causes of Kidney Disease in People Living with Diabetes...................................................................... 14

2
Therapeutic Approach to CKD in People Living with Diabetes –
Lifestyle Modification and Treatment Targets ................................................................................................................................................................................ 15
Disease Modifying Therapies for CKD in People Living with Diabetes............................................................................................................. 15
CASE STUDIES ................................................................................................................................................................................................................................................................................... 16
Singapore’s ‘War on Diabetes’.............................................................................................................................................................................................................................. 16
Screening and Managing People with Diabetes and CKD – The Uruguay Experience................................................................. 16
World Kidney Day.................................................................................................................................................................................................................................................................. 16
RECOMMENDATIONS............................................................................................................................................................................................................................................................. 17
RELEVANT RESOURCES.................................................................................................................................................................................................................................................... 18
REFERENCES.......................................................................................................................................................................................................................................................................................... 18

Acknowledgment
Editorial team
Anne Hradsky, Dr Antonio Ceriello, Beatriz Yáñez Jiménez, Federica de Giorgi, Dr Roberto Pecoits-Filho.

Contributors
Dr Adrien Liew, Dr Gloria Ashuntantang, Dr Laura Sola, Prof Roberto Pontremoli, Prof Salvatore De Cosmo,
Prof Per-Henrik Groop.
INTRODUCTION

About this Policy Brief

The International Diabetes Federation (IDF) and the International Society of Nephrology (ISN) have developed
this policy brief to target advocates, healthcare professionals and policy makers in the area of kidney disease
in people living with diabetes, with the aim of providing recommendations on actions required to prevent,
manage and treat this condition effectively.
This policy brief:
Highlights the links between diabetes and kidney disease, underscoring its impact and severity.
‡ 

Emphasises that we will only be able to address kidney disease in people with diabetes by
‡ 
developing a multisectoral approach to prevent and treat both conditions.
Provides policy recommendations to improve prevention and care and ultimately improve the lives
‡ 
of people living with, or at risk of, kidney disease in people with diabetes.
Shares life experiences of people living with both conditions and advocates for people-centred care
‡ 
and the inclusion of people living with diabetes and kidney disease in policy development.

About the International About the International

Diabetes Federation
The International Diabetes Federation (IDF) is the
global voice of the diabetes community. We are a non-
profit umbrella organisation of more than 240 national
diabetes associations in 161 countries and territories,
working together to improve and empower the lives
of the 540 million people estimated to be living with
diabetes and prevent diabetes in those at risk.
IDF activities aim to influence policy, increase public
awareness and encourage health improvement.
Our work covers seven regions where we support
national diabetes associations and promote
collaboration between them.
We collect and share high-quality information about
diabetes, advocate for the best possible standards of
care and prevention, and provide education for people
living with diabetes and their healthcare providers.
Our humanitarian activities prioritise the needs of
people with diabetes affected by a natural or human-
made disaster, particularly in low- and middle-income
countries.
Learn more about IDF at www.idf.org.
Society of Nephrology
The International Society of Nephrology (ISN) is a
global professional association dedicated to advancing 3
kidney health worldwide since 1960 through
education, grants, research and advocacy. The ISN is
advancing its mission by:
• Bridging the Gaps of available care through
advocacy and collaborations with our global
partners.
• Building Capacity in healthcare professionals
via granting programs, education and
research.
• Connecting our Community to develop a
stronger understanding of the management of
kidney disease.
The ISN, through its 8,500 individual members and
in collaboration with national and regional societies,
engages 30,000 health professionals in more than 160
countries to reduce the burden of kidney diseases and
provide optimal health care for people affected.
Learn more about ISN at www.theisn.org.
THE GLOBAL IMPACT OF
Key diabetes statistics
DIABETES AND KIDNEY
(2021) [1]:
DISEASE
537 million adults live with diabetes;
‡ 
and 90% live with type 2 diabetes
What is Diabetes [1]
45% of diabetes cases in adults (240
‡ 
Diabetes is a metabolic disorder characterised by million) are undiagnosed
high blood glucose (sugar) levels. Insulin, a hormone
Diabetes is responsible for 6.7
‡ 
secreted by the pancreas, facilitates the uptake of million deaths annually (excluding
glucose that arrives in the bloodstream from the food the mortality risks associated with
we consume into the body’s cells to produce energy. COVID-19)
However, in people with diabetes, the body either does Diabetes accounts for US$ 966 billion
‡ 
not produce enough insulin or the cells fail to normally of healthcare expenditure (11.5% of
respond to it, both leading to elevated blood glucose the total healthcare spent on adult
healthcare worldwide)
levels, known as hyperglycaemia. If left untreated,
these high blood glucose levels can over time cause 541 million adults have impaired
‡ 
damage to different organs and tissues, increasing glucose tolerance and 319 million
have impaired fasting glucose,
the risk of developing severe comorbidities, including significantly increasing their risk of
hypertension, cardiovascular events such as myocardial developing type 2 diabetes
infarction, stroke and heart failure, eye disease and
chronic kidney disease (CKD).
IDF estimates that 537 million adults aged 20-79

4
are currently living with diabetes, a number that is
predicted to rise to 784 million by 2045. There are
two main types of diabetes: type 1 and type 2. People
with type 1 diabetes often have little to no insulin
production and are commonly diagnosed in childhood
or early adulthood. Because of the body’s inability to
produce sufficient insulin, people with type 1 diabetes
rely on daily insulin injections to maintain blood glucose
levels within the normal range. A far more common
form of diabetes is type 2 diabetes, accounting for
approximately 90% of all cases. In people with type
2 diabetes, the body is unable to use insulin properly
because of insulin resistance. This can eventually lead
to a chain reaction in which the pancreas can no longer
produce sufficient insulin to manage the elevated
glucose levels in the blood. Lifestyle changes, including
increased physical activity and a healthy diet, are the
mainstay of treatment. However, over time, most
people with type 2 diabetes will require oral drugs,
insulin, or both to control their blood glucose levels[2].
What is Chronic Kidney Disease
Chronic kidney disease (CKD) is a progressive condition Key CKD statistics:
characterised by a gradual loss of kidney function. An estimated 850 million people live
‡ 
Because the kidneys play a critical role in filtering waste with chronic kidney disease (2017)
and excess fluids from the blood, malfunction can
The death rate in CKD has increased by
‡ 
lead to serious illness and kidney disease. High blood 42% in 17 years
glucose levels can damage the blood vessels in the
CKD is the 12th most common cause
‡ 
kidneys, increasing the risk of developing CKD. It is a of death in 2017 and it is estimated to
serious complication that can lead to kidney failure [3]. become the 5th most common cause
2040
CKD is currently one of the most prominent causes of
death and suffering as well as a major contributor to The burden of CKD in LMICs is very
‡ 
cardiovascular disease and heart failure. Due in part to large and is among the top 10 causes of
death
the rise in risk factors, such as obesity and diabetes,
the number of people affected by CKD has also A higher risk of premature mortality,
‡ 
been increasing, affecting an estimated 850 million cardiovascular events and kidney failure
are associated with CKD [6]
individuals worldwide. The Global Burden of Disease
(GBD) studies have shown that CKD has emerged as a CKD in people living with diabetes was
‡ 
leading cause of mortality worldwide [4]. In its advanced found in over 58% of people screened
at random for albuminuria and eGFR [7]
stages, CKD can lead to kidney failure, while treatment
with dialysis and kidney transplant associated with a
high burden to healthcare systems.
The non-profit organisation “Kidney Disease:
Improving Global Outcomes (KDIGO)” defines CKD
as “abnormalities of kidney structure or function
5
present for more than 3 months, with implications for
health [5].” Besides the cause, two measures are used
to classify CKD into five stages that reflect the disease
progression and severity. The first measure, described
as the estimated glomerular filtration rate (eGFR),
indicates how well the kidneys are filtering blood. The
second measure assesses the amount of the albumin
(a specific type of protein) in the urine, reported as the
albumin-to-creatine ratio (ACR), derived by dividing the
urine albumin concentration by the urine creatinine
concentration. In case the kidneys are not properly
functioning, the eGFR may be reduced, albumin
levels in the urine may be elevated (a state known as
albuminuria) or both may occur.

CHRONIC KIDNEY DISEASE IN PEOPLE LIVING WITH

DIABETES
People with prolonged uncontrolled blood glucose could develop a progressive
kidney disease leading to kidney function impairment and failure. CKD is a common
complication of diabetes and diabetes is one of the leading causes of kidney failure.
The gold standard for diagnosis of diabetic kidney disease would be based on a
kidney biopsy indicating kidney disease caused by diabetes. But, in people living with
diabetes, CKD is rarely confirmed by histology and the cause of CKD in diabetes can be
multifactorial and may present with various pathophysiological feature. Thus, “CKD in
people living with diabetes” is a more realistic representation as compared to the term
“diabetic kidney disease”.
Diabetes and Kidney Disease Prevalence Worldwide [1, 8]

Map 1. Estimated age-adjusted comparative prevalence of diabetes in adults (20-19 years) in 2021

Map 2. Estimated global prevalence of CKD

Geographic regional structure not based on ISN regional framework
 Anita Sabidi (Indonesia), living with type 1 diabetes and chronic kidney disease
I was diagnosed with type 1 diabetes in 1997. When I was pregnant with
my second baby in 2015, I experienced pre-eclampsia and nearly had a
stroke. I learned of my kidney disease when I was admitted to the ICCU. I had heard
of nephropathy before, but my doctor had never explained my risk of developing CKD.

Upon my kidney disease diagnosis, I received information on CKD and screenings

for diabetes-related complications. It was difficult, considering I had a newborn son
and was also processing my diagnosis. There were psychological effects, and I had to
work through them alone. I had no outside professional support. Thankfully, I had my
family. My mother and husband offered their kidney for a transplant, but I prefer to
follow my nephrologist’s plan to keep my kidneys as long as possible. I am also lucky
to have an amazing team of doctors led by my endocrinologist and nephrologist. We
communicate via WhatsApp, which makes consultations easy.

Of course, my daily routine changed completely, especially at mealtimes. I now limit my protein intake. In addition to
counting carbs, I monitor minerals and avoid processed foods and bottled drinks. I take medications to control protein
leaks. One medication was out of stock recently, so my kidney function was off target for several months until my
nephrologist prescribed a substitute.

Governments should act to improve diabetes education and awareness. People living with diabetes would have a much
better quality of life if they had proper healthcare access, availability of medicines and blood glucose monitoring across
the country. Talking about complications is very delicate. However, through targeted education, we can learn to manage
them. Society also needs to be educated to provide support and not stigmatise people with diabetes complications.

In alignment with these goals, in April 2021 WHO 7

Diabetes and Chronic Kidney
Disease on the Political Agenda
Globally, non-communicable diseases (NCDs), such as
diabetes, heart disease and kidney disease are leading
causes of mortality, with the prevalence of diabetes
approaching epidemic proportions. Because of the
increasing prevalence and global impact of NCDs on
healthcare, various international commitments are
aiming to address their burden and halt their rise.
In 2013, Member States adopted the World Health
Organisation (WHO) overarching goal of 25% reduction
of premature mortality from NCDs by 25% by 2025.
Member States further aligned on nine voluntary
targets on NCDs, including one aiming for 0% increase
in obesity and type 2 diabetes prevalence and another
on achieving 80% access to essential medicines and
devices by 2025.
At the United Nations (UN) level, the Sustainable
Development Goal (SDG) 3.4 target primarily aims to
prevent and treat NCDs and promote mental health
and well-being [9]. This sets a precedence for various
other policies to meet the overarching goal of the SDG
to reduce premature mortality from NCDs by one third
by 2030.
launched the Global Diabetes Compact, a global
initiative with a vision of reducing the risk of diabetes
and ensuring that all who are diagnosed with diabetes
have access to equitable, comprehensive, affordable
and quality treatment and care.
In May 2021, Member States adopted a Resolution on
reducing the burden of NCDs through strengthening
diabetes prevention and control. This resolution called
for urgent coordinated global action on diabetes
and tasked WHO with developing clear diabetes
recommendations and a set of diabetes targets to
address the gaps in diagnosis and access to care. As a
result, Member States adopted new global coverage
targets for diabetes in May 2022 – focusing on ensuring
access to equitable, comprehensive, affordable and
quality treatment for all.
Despite its prevalence and impact on premature
mortality, CKD is not featured as an indicator for any
NCD target at the UN or WHO level. Although CKD
was estimated to cause 1.2 million deaths in 2017 [10],
the WHO NCD Action Plan mentions kidney disease
only as a comorbidity or risk factor for diabetes and
cardiovascular disease. This could be due to a variety
of factors, such as kidney disease being considered
a component of a broader health issue or simply
because the targets were developed before kidney
disease received increased attention as a public health
concern. Because of the close association between
CKD and other NCDs, initiatives to prevent the risk of
and reduce premature mortality from NCDs, including
diabetes, will indirectly reduce premature mortality
from CKD. However, CKD management would benefit
from the development of global strategic action plans
specifically directed to tackling the condition. Kidney
disease needs targeted health interventions because it
is a complex and multifaceted condition that requires
specialised care and management. While kidney
disease may co-occur with other chronic conditions,
it is a distinct condition with unique clinical features,
risk factors and treatment considerations. By including
kidney disease specifically in UN and WHO targets, for
example in the political declaration on the upcoming
2025 UN High Level meeting on NCDs, policymakers
and stakeholders can increase awareness about
the importance of kidney health and improve the
allocation of resources to prevent, detect and manage
kidney disease.

WHO GLOBAL DIABETES COMPACT [11]

Why do we need to act?

Although premature mortality in other major non-communicable diseases (NCDs) has seen a
‡ 
downward trend, premature deaths due to diabetes have risen by 5% between 2000-2016.

In May 2022, Member States recognised the urgent need to act and adopted five historic global
‡ 
coverage targets for diabetes

What is the WHO Global Diabetes Compact?

In response to the increased burden of diabetes, the WHO Global Diabetes Compact (GDC) was launched 8
on the 100th anniversary of the discovery of insulin in April 2021. This global initiative has the vision of
reducing the risk of diabetes and ensuring that all who are diagnosed with diabetes have access to equitable,
comprehensive, affordable and quality treatment and care. It also aims to support Member States in
achieving the global coverage targets for diabetes and contribute to Sustainable Development Goal 3.4
(reducing premature mortality due to NCDs by one-third by 2030).

The WHO Global Diabetes Compact

works through six workstreams:
1. Access to essential diabetes medicine and
associated health technologies
2. Technical products
3. Prevention, health promotion and health
literacy
4. Country support
5. Research and innovation
6. Governance and partnerships
 Michael Donohoe (USA), living with type 2 diabetes and chronic kidney disease
I was diagnosed with type 2 diabetes in August 1996 and in November
2019 with diabetes-related kidney disease. Before my diagnosis, I had
heard about nephropathy because my father and paternal grandmother had the
condition. However, I received very little information from my doctor on my risk of
developing diabetes-related kidney disease.

After two and a half years, my primary care physician (PCP) referred me to a
nephrologist, who diagnosed me with Stage 3A chronic kidney disease (CKD). At that
point, I requested an appointment with a nutritionist who specialised in diabetes
and kidney issues. The nutritional advice, along with a change in medication,
stabilised my condition. In addition, the diagnosis caused me to change my diet,
work even harder on blood sugar control, and do light cardio exercise like walking.

I was also highly impacted psychologically. Kidney failure had killed my father and
my grandmother. Unfortunately, I did not receive any specific psychological support. My healthcare team, however,
has been supportive overall.

I feel that the government and organisations representing the interests of people with diabetes in my country need to
do more to prevent and treat diabetes-related kidney disease and improve the quality of life of people affected.

LINKS BETWEEN DIABETES Genes and family history

AND KIDNEY DISEASE Besides environmental and physiological factors,

The root causes of diabetes and CKD can be
multifactorial, as various genetic, environmental and
physiological factors influence their development and
progression. It is therefore important to understand
this complexity and develop a holistic management
approach to reduce the global disease burden of both
conditions.
Causes of Diabetes
Overweight, obesity and physical
inactivity
9
both type 1 and type 2 diabetes have a hereditary
component, increasing a person’s risk of developing
the condition. Studies indicate that type 2 diabetes
tends to cluster in families, with its prevalence varying
widely among populations. Some populations, such
as Asian Americans, African Americans and Native
Americans, have a higher probability of developing
type 2 diabetes compared to others. This genetic
predisposition to diabetes based on family history
or ethnicity can have a significant impact on the
development and progression of the disease.
Genetic mutations

Overweight and obesity can cause beta cell
dysfunction in the pancreas, which is responsible
for the production and secretion of insulin. People
living with overweight and obesity are prone to
developing insulin resistance, putting them at risk of
developing type 2 diabetes. A sedentary lifestyle with
physical inactivity, often resulting in higher body fat
accumulation, further increases the risk of developing
overweight, obesity and diabetes among other NCDs,
such as heart disease, stroke and cancer [12].
In addition to type 1 and type 2 diabetes, rare forms
of diabetes can result from mutations in a single gene
(i.e. monogenic) that are usually inherited from one
or both parents, though in some cases the mutations
happen spontaneously. Examples of such rare forms of
diabetes include maturity-onset diabetes of the young
(MODY) and neonatal diabetes. In most of these
cases, the mutation renders the pancreas less capable
of producing insulin. MODY is the most common form
of monogenic diabetes, typically diagnosed during
adolescence, whereas neonatal diabetes occurs in the
first 6 months of life and can be either permanent or
transient [13].
Diabetes can also result from other genetic disorders.
One of these is cystic fibrosis in which thick mucus
can cause scar tissue in the pancreas, preventing it
from producing insulin. Another condition, called
haemochromatosis, similarly increases the risk of
developing diabetes because of iron accumulation
that can damage the pancreas and other organs, if left
untreated [14, 15].
Other endocrine diseases
Generally, endocrine diseases affect the glands that
secrete various hormones in the body, resulting in
a hormonal dysfunction or disorder. While diabetes
itself is an endocrine condition affecting the pancreas,
abnormal function of the endocrine system induced
by endocrine conditions other than diabetes can lead
to insulin resistance because of the overproduction
of certain hormones, such as cortisol in Cushing’s
disease, growth hormone in acromegaly and thyroid
hormone in hyperthyroidism [16].
Damage to or removal of the pancreas
Damage to the pancreas and consequently the beta
cells that produce insulin can occur due to pancreatitis,
pancreatic cancer or trauma, while removal of the
damaged pancreas can also lead to diabetes because
of the loss of beta cells [17].
Drugs
Drug-induced diabetes can be caused by various
mechanisms, including damage to the beta cells,
inhibition of insulin function, insulin resistance,
decreased insulin production and glucose
intolerance. Steroids, antipsychotics, antiretrovirals,
chemotherapy, diuretics, transplant immune-
suppressants, among others, and can all be associated
with hyperglycaemia due to drug-induced diabetes [18].
Causes of Chronic Kidney Disease
CKD is a common comorbidity of other diseases, with
diabetes and hypertension being responsible for two-
thirds of CKD cases worldwide [19]. Both high glucose
levels from uncontrolled diabetes and hypertension
can cause damage to the blood vessels in the kidneys,
affecting their ability to filter blood, leading to kidney
malfunction. In addition, the inability of the kidneys to
filter blood effectively can exacerbate hypertension.
As a result, CKD, diabetes and hypertension are highly
interrelated comorbidities, worsening each other.
Obesity is a growing concern as a major risk factor
for developing CKD. The association between obesity
and CKD is bidirectional and can be explained by
the pathophysiological pathways, risk factors and
comorbidities that both these diseases have in
common [20]. Obesity is also linked to the risk of CKD
in diabetes, specifically in type 1 diabetes, obesity
and CKD in people with diabetes share a causal
relationship [21].
Besides diabetes, hypertension and obesity there are
a few other conditions that can cause CKD. Diseases
affecting the kidneys such as glomerulonephritis,
congenital kidney and urinary tract abnormalities,
polycystic kidney disease and autoimmune diseases
can contribute to CKD. It can also be a consequence
of physical obstruction in the kidneys, due to stones
or a tumour, an enlarged prostate or recurrent urinary
tract infections.
10
Causes of CKD in People Living
with Diabetes
CKD commonly occurs in people with both type 1 and
type 2 diabetes. It is characterised by progressively
impaired kidney function and ultimately kidney
failure contributing to high morbidity and mortality in
Salih Hendricks (South Africa), living with diabetes and chronic kidney disease
In 1978, at the age of 12, I was diagnosed with diabetes insipidus, a
rare disorder that causes the body to make too much urine because of a
hormone imbalance. Before then, I had never heard of kidney disease. My doctor at
that moment, who was a diabetes-kidney specialist, explained my risk of developing
kidney disease.

In 1983, I had diabetic ketoacidosis (DKA) and was diagnosed with type 1 diabetes and
kidney disease. Before then, I had many kidney disease symptoms. My blood pressure
was high. I also had protein and blood in my urine and an increased need to urinate.
My feet, ankles and hands were swollen, and I had shortness of breath. I lost weight
because my appetite was gone. Lastly, I had difficulty focusing and concentrating in
school.

After my diagnosis, my daily life as a teenager changed at school and home, including
my eating habits and the sports I played. No psychological support was available, which as a boy of 12, made my
condition even more challenging to accept. From then until today, I have been dealing with the psychological impact of
my diagnosis and trying to cope.

Since my diagnosis, I have taken hypertension medication. My kidney function has improved because of better circulation
due to controlled insulin intake and a partial leg amputation.

My family has been very supportive, especially since I come from a “diabetes family” who understands the complications
and issues related to the condition. In addition, the team at my diabetes clinic has been equally wonderful and supportive.

Access to new technology has improved the control and care management of my diabetes and kidney disease. I think
governments must do more for prevention and access to improve the quality of life of people with these conditions.
11

diabetes. Although kidney damage could result from

long-term exposure to high blood glucose levels in
diabetes, kidney disease in people living with diabetes
can often be multifactorial. Kidney disease in diabetes
is characterised by impairment of metabolism and
hence can present with various pathophysiological
features that may be related and also unrelated to
diabetes.

CKD in People Living with Diabetes:

Implications for Cardiovascular Risk
and Total Mortality
Cardiovascular disease represents the leading cause
of death and disability among people with diabetes
in whom the incidence of stroke, coronary artery
disease and peripheral artery disease is higher
compared to the general population [19]. Evidence to
suggests a link between high blood glucose levels
and atherosclerosis, the hardening and narrowing
the arteries, which reduces blood flow. Nevertheless,
besides uncontrolled blood glucose levels, many other
factors, including genetics, ethnicity, gender, obesity,
age, lifestyle habits, blood pressure and blood lipids,
influence the risk of developing cardiovascular disease.
The cardiovascular risk in people with diabetes
further increases in the presence of CKD, which in
itself represents a well-known cardiovascular risk
predictor. A reduction in kidney function together
with an increase in urine albumin excretion results
in a three- to five- fold increased risk of developing
cardiovascular complications, negatively affecting the
prognosis and life expectancy of people with diabetes
and kidney disease versus those with normal kidney
function. Diabetes, occurrence of cardiovascular
disease and development of early CKD are associated
with a reduction in life-expectancy of an individual by
6, 12 and 16 years respectively.
Kidney disease in people living with diabetes,
exponentially increases the risk of experiencing a
macrovascular event and premature death. Hence,
most people affected die prematurely before
progression to kidney failure and before requiring
kidney replacement therapy, either through dialysis
Map 3: Incidence of deaths due to diabetes and kidney disease [22]
or kidney transplantation. Clinical research therefore
prioritises the prevention and treatment of CKD to
reduce the burden of cardiovascular diseases and
improve the life expectancy of people with diabetes.
Given the substantial morbidity and mortality of
cardiovascular disease in people with diabetes, it
is not surprising that treatment is generally not
limited to blood glucose lowering drugs, but instead
also consists of non-pharmacological measures and
pharmacotherapy to prevent and treat cardiovascular
disease and its risk factors. Pharmacological strategies
aim to reduce cardiovascular complications by
focussing on controlling blood pressure, reducing
blood lipids and preventing atherosclerosis with anti-
thrombotic agents to eventually improve the quality of
life and life expectancy of people with living diabetes
and CKD. More recently, encouraging results have
also been described with anti-inflammatory drugs to
manage cardiovascular disease.
12
The Impact of CKD for People
Living with Diabetes and Healthcare
Budgets
As described above, diabetes, hypertension and CKD
are frequent comorbidities contributing to about
80% of end-stage kidney disease globally. In addition,
these conditions often lead to the development of
cardiovascular diseases, reducing a person’s quality of
life and life expectancy [23].
Because of the morbidity and mortality, CKD in people
living with diabetes substantially increases the health
expenditure. In the United States, healthcare costs of
people with diabetes and CKD were reported to be
about 50% higher than those of people with diabetes
but no CKD [24]. In addition, for people progressing
to kidney failure, the costs for dialysis and kidney
transplant create a significant economic burden to
healthcare. Hence, the most effective strategies
to reduce the economic impact of diabetes and its
comorbidities are those focussing on prevention.
In case people are already affected by diabetes, it is
essential to screen, diagnose and treat CKD in its early
stages to prevent further complications and reduce
the impact on healthcare budgets [23, 25].
13

Perseus Propere (Saint Lucia), living with type 1 diabetes and chronic kidney
disease
I was diagnosed with type 1 diabetes in 1991, when I was seven. In 2008,
after 17 years living with diabetes, I was diagnosed with stage 2 kidney
disease.

Before my diagnosis, my doctor explained that I was at risk of CKD. But I was young
and did not think I was at risk, so I never paid much attention.

My entire life changed. Every day, my swollen feet and ankles and shortness of breath
made physical activity more and more difficult. In addition, my diet and eating habits
completely changed. I had to drink fewer liquids and reduce sodium, potassium and
phosphorus in my meals. I was 25 and felt like an elderly person. To make things
worse, I was made redundant because I had to take time off for medical care.

The diagnoses of retinopathy and kidney disease affected me psychologically.

Because of my age, it really impacted my mental health. I had suicidal thoughts, depression and
anxiety, so I met with a counsellor to talk through my feelings. Thankfully I had my family and friends, who were my
biggest support team!

If more information had been available about diabetes, I wouldn’t have the health issues I have today. There should
be more sustainable and affordable diabetes prevention and management programmes. This includes more dialysis
centres, a viable government transplant system, increasing access to healthcare and essential medications, and
diabetes education and awareness.
ADDRESSING DIABETES
AND CKD IN PEOPLE
LIVING WITH DIABETES
Diabetes Prevention
Prevention of type 2 diabetes is a key strategy in
reducing the diabetes burden. Several clinical trials
have demonstrated that lifestyle intervention,
consisting of an individualised reduced-calorie meal
plan and appropriate physical activity, are highly
effective in preventing or delaying type 2 diabetes and
in improving other cardiometabolic markers, such as
blood pressure, blood lipids and inflammation [26, 27,28].
In agreement with the outcomes of these studies, the
American Diabetes Association (ADA) recommends
that adults living with overweight and obesity at high
risk of developing type 2 diabetes achieve weight loss
by decreasing their caloric intake and implementing
moderate intensity exercise regimens. Although
type 1 diabetes cannot be prevented, strategies to
avoid the onset or progression of chronic diabetes
complications can improve quality of life and lower
the economic burden over time [18]. It is important to
emphasise that many cases of type 2 diabetes are due
to genetic factors and cannot be prevented through
lifestyle interventions.
Screening for CKD in People Living
with Diabetes
In many countries, screening for diabetes in adulthood
has been proposed as a public health policy. Evidence
suggests that screening for diabetes is cost-effective,
with screening strategies reducing the incidence of
developing complications, such as cardiovascular
disease [29]. For example, the ADA recommends
repeated screening of asymptomatic adults from 35
years onwards for prediabetes and type 2 diabetes
with a minimum of three years intervals along with an
assessment of risk factors, including overweight and
obesity [18].
In addition, for people diagnosed with type 2 diabetes,
current guidelines recommend that all should be
screened annually for kidney disease from diagnosis
onwards, whereas, in type 1 diabetes, annual
screening should begin no later than five years from
initial diagnosis. As described above, kidney function
is assessed by measuring the amount of albumin in
the urine and estimating the glomerular filtration rate
of the kidneys, two markers associated with mortality,
cardiovascular disease, heart failure and progression
to kidney failure [30]. Despite a strong recommendation
to screen for CKD the screening remains suboptimal [31]
Addressing the Different Causes
of Kidney Disease in People Living 14
with Diabetes
Although the causes of CKD in people living with
diabetes can be multifactorial, the most important
risk factors remain hyperglycaemia, obesity and
hypertension and blood lipid abnormalities. These
factors can all be improved through optimised and
intensive diabetes management, significantly reducing
the cumulative incidence of albuminuria, kidney
impairment and kidney failure.
Therapeutic Approach to CKD in Disease Modifying Therapies for
People Living with Diabetes – CKD in People Living with Diabetes
Lifestyle Modification and Apart from the lifestyle modifications and treatment
Treatment Targets targets for managing CKD in people living with
diabetes, several intervention strategies, both well-
A comprehensive treatment plan, involving both the
established and recently introduced disease modifying
person affected and physician, should be outlined for
therapies have emerged over the years. First, renin-
the treatment of CKD in people with diabetes. Lifestyle
angiotensin-aldosterone system (RAAS) inhibition has
modifications represent the cornerstone of treatment
been the cornerstone of treatment for people with
but can be supplemented with pharmacological
CKD for nearly 30 years. More recently, a range of
interventions if needed to preserve organ function
added treatment options offers healthcare providers
and maintain control over blood glucose levels, lipids
more possibilities for preventing and delaying the
and blood pressure.
progression of CKD in people living with diabetes.
The most common approaches for pharmacological
Some of these new therapeutics include [32]:
management of CKD in people living with diabetes
include: • A sodium–glucose cotransporter 2 inhibitor
(SGLT2i) promotes the renal excretion
• Blood pressure control: Reducing blood
of glucose, lowering glucose levels in
pressure in people with diabetes is essential
the blood. Because of its proven kidney
in controlling the progression to kidney
and cardiovascular benefit, SGLT2i is
disease. Angiotensin-converting enzyme (ACE)
recommended in people with type 2 diabetes
inhibitors or angiotensin II receptor blockers
and CKD.
(ARBs) are recommended drug classes for
people with type 1 and type 2 diabetes who • A glucagon-like peptide 1 (GLP-1) receptor
have hypertension and albuminuria, titrated agonist can be considered in people who do 15
to the maximum antihypertensive or highest not achieve optimal glycaemic control with
tolerated dose. metformin and/or an SGLT2i or for those with
contraindications to these drugs. GLP-1 acts
• Lipid control: To reduce the risk of developing
by facilitating insulin secretion and has proven
cardiovascular disease from blood lipid
cardiovascular benefit as well as reduces
abnormalities, statins are recommended for
albuminuria. It is therefore recommended for
people with both type 1 and type 2 diabetes.
people with type 2 diabetes and CKD.
Statins act by controlling cholesterol levels,
preventing the development of atherosclerotic • A nonsteroidal mineralocorticoid receptor
cardiovascular disease in those with known antagonist (ns-MRA) is known to prevent
atherosclerotic cardiovascular disease and in inflammation and fibrosis of the kidney and
those at risk. heart, providing kidney and cardiovascular
benefit and being a possible add-on therapy
• Blood glucose control: Long-term glycaemic
for CKD in people living with diabetes.
control reduces the risk of organ damage
and associated comorbidities in people with
diabetes. Blood glucose-lowering drugs, along
with lifestyle changes, are recommended
for people with type 2 diabetes to improve
glycaemic control.
CASE STUDIES World Kidney Day
World Kidney Day is an annual global campaign that
Singapore’s ‘War on Diabetes’ raises awareness about kidney health and the impact
of kidney disease worldwide. The campaign was first
A great initiative to bring global targets and launched in 2006 by the International Society of
recommendations into practice was undertaken by Nephrology (ISN) and the International Federation of
the Singapore Government. In 2016, The Singapore Kidney Foundations (IFKF). Each year, World Kidney
Government declared the “War on Diabetes”, Day has a specific theme that highlights a different
mobilising citizens to raise awareness of diabetes aspect of kidney health, such as prevention, detection,
by generating community-based recommendations or management of kidney disease. The campaign has
on diabetes prevention and management. These grown significantly since its inception, with events and
engagement models are based on the belief that activities now taking place in more than 100 countries
citizens can contribute meaningfully to the co-creation around the world.
and co-delivery of approaches on issues of significance
to them and the community [33]. While it is difficult to determine the direct impact
of World Kidney Day on the prevalence of kidney
disease globally, the campaign has had a significant
Screening and Managing People impact on increasing awareness and advocacy
with Diabetes and CKD – efforts for kidney health, which can help to improve
The Uruguay Experience prevention, diagnosis, and management of kidney
disease. It is common for Ministries of Health to be
Although Latin America is a heterogenous region
involved in World Kidney Day activities, as they are
with inequities in access to healthcare between
responsible for promoting public health and ensuring
different countries, in Uruguay, policy interventions
that adequate resources are allocated to address the
16
have resulted in positive health impacts. Since 2009,
burden of kidney disease in their respective countries.
a decree by the Department of Health includes
Ministries of Health may participate in a variety of
screening for CKD in high-risk populations (“case-
World Kidney Day activities, such as organising health
finding”) as part of the mandatory health check-ups
screenings, promoting awareness campaigns, or
of the working population. These health check-ups
hosting educational seminars.
consist of a mandatory twice-yearly urine exam and
serum creatinine tests in people with diabetes and
hypertension. If the tests are abnormal, the person
affected is referred to a general physician to confirm
the findings, determine the treatment regimen and
decide if a referral to nephrology is needed. In addition
to this screening approach, dialysis has been a part
of universal health coverage since 1981. Both these
measures have resulted in an improvement in the
quality of care along with a reduction in the incidence
of CKD [34].
According to the guidelines for diabetes in Uruguay,
attention should be given to control both blood
pressure and albuminuria [34]. Although this can
be achieved by using drugs that act on the renin-
angiotensin-aldosterone system, diabetes care would
benefit from universal and affordable access to other
add-on treatments, such as SGLT2 inhibitors, that are
currently not available (for all the people affected who
will benefit of their use) in Uruguay and most other
Latin American countries.
RECOMMENDATIONS
CKD in people living with diabetes is common, the consequences are grim
and we need to take action. IDF and ISN recommendations:
1. Ensure intersectoral and
multisectoral collaboration in the
development of comprehensive
policies and investments to prevent
and treat diabetes and CKD
2. Collaborate with WHO to implement
the Global Diabetes Compact at the
national level, to improve diabetes
prevention and care
3. Develop and implement
interventions to facilitate
diabetes screening across the
entire population, according to
recommendations
4. Provide universal coverage
to glycaemia and glycated
haemoglobin tests, glucose lowering
drugs and antihypertensive
treatment drugs, in line with the
WHO diabetes coverage targets to
be achieved by 2030
5. Develop and implement
programmes for CKD screening,
risk stratification and monitoring in
people with diabetes
6. Provide universal coverage for
drugs that reduce CKD progression
in people living with diabetes: ACE
inhibitors/ARB, SGLT2 inhibitors and
MRA
7. Provide universal coverage for
CKD care, including dialysis and
transplantation, which are critical
components of the treatment and
management of end-stage kidney
disease and must be included in
any comprehensive universal health
coverage programme
8. Include kidney disease specifically in
UN and WHO targets, for example
in the political declaration on the
17
upcoming 2025 UN High Level
meeting on NCDs, to increase
awareness about the importance
of kidney health and improve the
allocation of resources to prevent,
detect and manage kidney disease
9. Advocate for people-centred care
and ensure that people living with
diabetes and CKD are included in
the development and evaluation of
interventions and guidelines
RELEVANT RESOURCES
• A single number for advocacy and communication—
worldwide more than 850 million individuals
have kidney diseases: https://www.theisn.org/
blog/2019/09/30/a-single-number-for-advocacy-
and-communication-worldwide-more-than-850-
million-individuals-have-kidney-diseases/; 2019
KI_ASN_ERA-EDTA_ISN_Kidney Disease.pdf

• Global Kidney Health Atlas: https://www.theisn.org/

initiatives/the-isn-closing-the-gaps-ckd-initiative/

• 10 Recommendations To Global Kidney Health:

https://www.theisn.org/in-action/advocacy/
advocacy-activities/10-recommendations-for-
global-kidney-health/

• Diabetes basics: https://idf.org/about-diabetes/

introduction/

• Data portal of the IDF Diabetes Atlas 2021: https://

diabetesatlas.org/data/en/

• IDF guide to data-driven advocacy: https://idf.org/

media/uploads/2023/05/attachments-27.pdf

• Map 2 Source: Hill et al., Global prevalence of 18

chronic kidney disease - a systematic review and
meta-analysis.

• Global Coalition for Circulatory Health White

papers: https://www.theisn.org/in-action/
advocacy/policies-campaigns/#gcch
REFERENCES
1. International Diabetes Federation. IDF Diabetes
Atlas, 10th edn. Brussels, Belgium: International
Diabetes Federation, 2021.
2. www.idf.org
3. United States Renal Data System. 2022 USRDS
Annual Data Report: Epidemiology of kidney disease
in the United States. National Institutes of Health,
National Institute of Diabetes and Digestive and
Kidney Diseases, Bethesda, MD, 2022.
4. “Analysis of the Global Burden of Disease study
highlights the global, regional, and national trends
of chronic kidney disease epidemiology from 1990
to 2016”. by Yan Xie et al. published in Kidney
Int. 2018 Sep;94(3):567-581.
5. Kidney Disease: Improving Global Outcomes
(KDIGO) Diabetes Work Group. KDIGO 2022 Clinical
Practice Guideline for Diabetes Management in
Chronic Kidney Disease. Kidney Int, 2022. 102(5S):
S1-S127
6. Afkarian, M., et al., Kidney disease and increased
mortality risk in type 2 diabetes. J Am Soc Nephrol,
2013. 24(2):302-8.
7. Parving, H.H., et al., Prevalence and risk factors
for microalbuminuria in a referred cohort of type
II diabetic patients: A global perspective. Kidney
International, 2006. 69:2057-2063
8. https://www.theisn.org/wp-content/
uploads/2021/05/GKDAtlas_2017_FinalVersion-1.
pdf
9. www.undp.org/sustainable-development-
goals [Date accessed: 2 February, 2023]
10. World Health Organization. Global action plan for
the prevention and control of noncommunicable
diseases 2013-2020. World Health Organization,
2013. https://www.who.int/publications/i/
item/9789241506236
11. https://www.who.int/health-topics/physical-
activity#tab=tab_1 [Date accessed: 2 February,
2023]
12. www.who.int/health-topics/
physicalactivity#tab=tab_1) [Date accessed: 2
February,2023]
13. Zhang, H., et al., Pollin Monogenic diabetes: a
gateway to precision medicine in diabetes. J Clin
Invest, 2021.
14. Coderee, L., et al., The potential causes of cystic
fibrosis-related diabetes. Front Endocrinol, 2021.
30:12 702-823
15. Utzschneider, K.M., et al., Hereditary
hemochromatosis and diabetes mellitus:
implications for clinical practice. Nat Rev Endocrinol,
2010. 6(1):26-33.
16. Resmini, E., et al., Secondary diabetes associated
with principal endocrinopathies: the impact of
new treatment modalities. Acta Diabetol, 2009.
46(2):85-95
17. Fève, B., et al., When therapeutic drugs lead to
diabetes. Diabetologia, 2022. 65:751–762
18. American Diabetes Association Professional
Practice Committee; 2. Classification and Diagnosis
of Diabetes: Standards of Medical Care in
Diabetes—2022. Diabetes Care, 2022; 45 (S1): S17–
S38.
19. Kovesdy, C.P., Epidemiology of chronic kidney
disease: an update 2022. Kidney Int Suppl 2011, 19
2022. 12(1):7-11
20. Lakkis, J.I., et al., Obesity and Kidney Disease. Prog
Cardiovasc Dis, 2018. 61(2):157-167
21. Todd, J.N., et al., Genetic Evidence for a Causal Role
of Obesity in Diabetic Kidney Disease. Diabetes,
2015. 64:4238–4246
22. https://www.thelancet.com/lancet/visualisations/
gbd-compare [Date accessed: 22 March, 2023]
23. International Diabetes Federation. IDF Diabetes
Atlas, 9th edn. Brussels, Belgium: International
Diabetes Federation, 2019.
24. Li, R., et al., Medical costs associated with type 2
diabetes complications and comorbidities. Am J
Manag Care, 2013. 19(5): p. 421-30.
25. Sakthong, P., et al., Cost-effectiveness of using
angiotensin-converting enzyme inhibitors to
slow nephropathy in normotensive patients with
diabetes type II and microalbuminuria. Nephrology,
2001. 6(2):71-77
26. Knowler, W.C., et al., Reduction in the incidence 30. KDOQI. KDOQI Clinical Practice Guidelines and
of type 2 diabetes with lifestyle intervention or Clinical Practice Recommendations for Diabetes and
metformin. N Engl J Med, 2002. 346(6): p. 393-403. Chronic Kidney Disease. Am J Kidney Dis, 2007. 49:
S12–154
27. Lindstrom, J., et al., Finnish Diabetes Prevention
Study Group. Sustained reduction in the incidence 31. https://pubmed.ncbi.nlm.nih.gov/28434650/
of type 2 diabetes by lifestyle intervention: follow-
32. de Boer, I.H., et al., Diabetes management in
up of the Finnish Diabetes Prevention Study. Lancet,
chronic kidney disease: a consensus report by the
2006. 368:1673–1679
American Diabetes Association (ADA) and Kidney
28. Li, G., et al., Cardiovascular mortality, all-cause Disease: Improving Global Outcomes (KDIGO).
mortality, and diabetes incidence after lifestyle Kidney Int, 2022. 102(5): p. 974-989.
intervention for people with impaired glucose
33. Yang, C.W., et al., Global case studies for chronic
tolerance in the Da Qing Diabetes Prevention
kidney disease/end-stage kidney disease care.
Study: a 23-year follow-up study. Lancet Diabetes
Kidney Int Suppl (2011), 2020. 10(1): p. e24-e48.
Endocrinol, 2014. 2:474–480
34. www.moh.gov.sg/wodcj [Date accessed: 2
29. Kahn, R., et al., Age at initiation and frequency
February, 2023]
of screening to detect type 2 diabetes: a
cost-effectiveness analysis. Lancet, 2010.
375(9723):1365-1374
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and preventing diabetes in those at risk Together.

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